NCD Prevention: The historical perspective and vision for ... · NCD Prevention: The historical perspective and ... (rapeseed and soyabean oils) ... NCD Prevention: The historical

NCD Prevention: The historical

perspective and vision for the future

Pekka Puska, MD, PhD, MPolScDirector General, National Institute for Health and Welfare (THL), FinlandPresident, Int. Association of National Public Health Institutes (IANPHI)

THE PROBLEM• Heavy burden of NCD’s• Inequalities (geographic,

population groups)

3.12.2013 Pekka Puska, Director General 2



Myths about chronic noncommunicablediseases and their prevention

• Diseases of mainly old people• Diseases of men• Causes are genetic• Difficult of prevent• Expensive to prevent• Prevention may help the next generation• ”Diseases of affluence”• Individual’s responsibility



NONCOMMUNICABLE DISEASES HAVE MOVED TO POORER AND

POORER COUNTRIESAND

WITHIN COUTRIES NCD’S AND THEIR RISK FACTORS HAVE MOVED TO LOWER SOCIO-

ECONOMIC SEGMENTS OF THE POPULATION


• Most NCD’s are from medical point of view to great extent and to late in life preventablediseases

• Treatment of NCD’s is possible, but the big potential from public health point of view is in population based prevention!

• Population based prevention through influencingNCD related lifestyles (through health promotionand policies) is the most cost-effective and sustainable way to improve public health!


NCD prevention effective

The effects of prevention (riskfactor reduction) are (particularlyfor cardiovascular diseases and diabetes)• surprisingly rapid and• concern also relatively old ages


Rapid impact of risk factorchanges on CHD and diabetes rates• Stopping smoking and AMI risk• Introduction of smokefree restaurants• Cholesterol lowering in lipid trials• Lowering of T2 diabetes rates in

diet/PA interventions• Changes on population level

(Finland/North Karelia, Poland etc.)


Introduction of smokefree restaurants: Impact on AMI (Acute MyocardialInfarction) ratesReviews Amirate reduction

Meyers et al. (2009): -17 % (11 studies)Mackey et al. (2010): -10 % (17 studies)Lin et al. (2013): -13 % (18 studies)


DIABETES PREVENTION STUDY, FINLAND

Lindström et al, Lancet 2006:368;1673-79

0

10

20

30

40

50

Cum

ulat

ive

inci

denc

e of

T2D

, %

0 1 2 3 4 5 6 7 8

Follow-up time, years

Intervention

Control

Intervention ceased


Change in age-adjusted mortality rates Finland, males aged 35–64 (per 100 000 population)

extension of the Projectnationally

start of the North Karelia Project

North Karelia -85%

All Finland -80%

Rate per 100 000

1969-1971

2006 Change from 1969-1971 to 2006

All causes 1328 583 -56%

All cardiovascular

680 172 -75%

Coronary heart disease

489 103 -79%

All cancers 262 124 -53%

Coronary heart disease

Gain of some 10 healthy yearsin Finnish population

3.12.2013 13Pekka Puska, Director General

The ”natural experiment” in Poland (also in Check, Slovakia, Hungary and Slovenia) in the 1990’s (Zatriski, Campos & Willet 2008)

• The market transformation in early 1990’s corresponded with a rapid and remarkable decline in CHD

• The decline occurred in both sexes and in all populationgroups

• ”These countries had probably the most rapid decrease in CHD ever observed”

• The market transformation gave rise to fundamental changesin diet: butter and animal fats became more expensive, vegetable oil consumption doubled or tripled

• The decline was particularly associated with consumption of oils rich in alpha-linolenic acid (rapeseed and soyabean oils)



Change in coronary heart diseasemortality in North Karelia from 1969 – 71 to 2006 according to age group

Age group Change in men

CHD mortalitywomen

35 – 44 -96 % (-44 %)*45 – 54 -91 % -89 %55 – 64 -80% -92 %65 – 74 -69 % -82 %


* Very few cases

”There is too much optimism in prevention of infectious diseases

andtoo much pessimism about

prevention of noncommunicablediseases”


NCD prevention is not expensive• Influencing lifestyles through health promotion

and policies is usually cheap• Even best buy basic prevention services are

usually inexpensive and cost effective (WHO)• Example: Raising alcohol tax in Finland during

the last 3 – 4 years increased governmentrevenue appr. 400 million euros and reducedalcohol consumption 10 %

• Costs of clinical medicine for treatment of CVD, cancer, COPD, diabetes etc. are very high.


NCD prevention• Science base strong• Evidence based strategies• Effective actions

(WHO global NCD action plan)


WHO’s global NCD strategy, 2000

• NCD prevention and control is a globalhealth priority

• Comprehensive action is needed, but frompublic health point of view populationbased prevention is the key (most cost-effective and sustainable)

• Integrated prevention: targeting common, lifestyle related risk factors (tobacco, diet, physical activity, alcohol)


UN high-level summit on NCDsNew York Sept 2011

• Preceded by Ministerial Conference in Moscow (April 2011).

• Political declaration• Action on global NCD

prevention and control”• WHO’s leadership,

intersectoral support


WHO global action plan 2013-201. International cooperation and advocacy2. Strengthen national capacity, leadership, governance,

multisectoral action and partnership3. Reduce risk factors through health-promoting environments4. Strengthen and reorient health systems for prevention and

control of NCDs5. Promote national capacity for research for prevention and

control of NCDs6. Monitor trends and determinants of NCD and evaluate

progress



Observed and Predicted Declines in CoronaryMortality in Eastern Finland, Men

-90-80-70-60-50-40-30-20-10

0

1972 1977 1982 1987 1992 1997 2002 2007Year

%

ObservedPredictedCholesterolBlood pressureSmoking

3.12.2013 Pekka Puska, Director General

3a Reduce risk factors: tobacco• Increase tobacco tax• Completely smokefree

indoor places by law• Effective health

warnings and media campaigns

• Ban all tobaccoadvertising, promotionand sponsorship


3b Reduce risk factors: alcohol

• Increase alcohol tax• Comprehensive

restrictions and banson adventising and promotion

• Restrictions in the availability of retailedalcohol


3c Reduce risk factors: unhealthydiet and physical inactivity• Salt reduction through

industry and media campaigns

• Reduction of saturatedfat and replacement of transfats

• Public awarenesscampaigns on diet and physical activity


Redirection of health services


• Reorientation and strengthening of healthsystems

• Primary health care: ”Now more than ever” (WHR 2008)

• Special emphasis for NCDs• Chronic care model• Preventive practices

6. Monitor and evaluate• Develop national targets and indicators

(based on the global ones)• Develop national surveillance monitoring

system–Cause of deaths register–Cancer register–Periodic population risk factor surveys–Monitoring of national actions


NCD FRAMEWORK FOR ACTION/MONITORING

DETERMINANTS RISK FACTORSbehavioral biological NCD

Outcome(death etc)

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GENETICS

Health promotion

Prevention Treatment

SOCIETAL RESPONSES(HiAP)

HEALTH SERVICES

Pekka Puska, Director General

Pekka Puska, Director General 31

Personal Responsibility”Nobody can take better care of your health than yourself”

Public Responsibility”Make the healthy choices the easy ones”

(Ottawa charter)

COMBING PERSONAL AND PUBLIC RESPONSIBILITIES

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18

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PUBLIC RESPONSIBILITY

POLICY INTERVENTIONS

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Vision for the future• The future is in our hands: The

evidence is there• From what to how• Political will and leadership• From predicting the future to making

the future


During the last few years a great number of strategies and plans for evidence-based, effective prevention and health promotion have been produced


Many important priorities have been identified

Pekka Puska, Director General

IDENTIFYING IMPLEMENTINGPRIORITIES THEM

FROM PRIORITIES TO IMPLEMENTATION

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Implementation gap

36

Intersectoral work towards prevention- ”Health in all policies”• People’s lifestyles are influenced by decisions in

different sectors of society (much of them beyond the health sector)

• Social change process combining government policies, expert guidance, broad health promotion and mobilization of people

FINNISH EXAMPLES

Pekka Puska, Director General3.12.2013 37

Important elements of Finnishtobacco policy• No advertizing or sales promotion (since 1978)• Public indoor places, restaurants and work sites

smokefree• Pictorial health warnings• Sale to minors (below 18) prohibited• Tobacco products not at display• Sale of smokeless tobacco prohibited• Support to cessation and campaigns• Taxation

PREVALENCE OF DAILY SMOKING 16 %


Examples of intersectoral work 1.

Development of Finnish Rapeseed oil

Fen: y = -0.16x + 362

Gen: y = -0.16x + 358

414242434344444545

1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

g/k

g

Fen

Gen

Change in fat content of Finnish cow milk


Examples of intersectoral work 2.Biscuit example:• Leading Finnish biscuit manufacturer (LU Finland Ltd) has

removed some 80.000 kg of SAFA by changing the fats used• All trans fats removed and major transfer to rapeseed oil

Meat product example:HK (Leading Finnish meat company)since 2007 annually:• 40.000 kg less salt• 100.000 kg less saturated

fat in their products 1975 1980 1985 1990 1995

YEAR

1.6

1.8

2.0

2.2

2.4

Salt co

ncentra

tion (%

)

g


Pekka Puska, Director General3.12.2013

Berry project in North Karelia• To promote berry farming, product development and

consumption • Dairy farmers could switch over to berry farming• Financing from Ministries of Agriculture and Commerce

Finnish Heart Symbol

Examples of intersectoral work 3.

Serum Cholesterol in Finland, Men Aged 30–59 Years

FINRISK Studies 1997 & 2002

mmol/l

5

5,5

6

6,5

7

7,5

1972 1977 1982 1987 1992 1997 2002 2007

North KareliaKuopioTurku/LoimaaHelsinki/VantaaOuluLapland

Pekka Puska, Director General3.12.2013

8th Global WHO Conference on health promotion - “Health in all policies”

From Ottawa to Helsinki (June 2013)


HELSINKI STATEMENT

Ban Ki-Moon:”We should all work to meet the targets to reduce NCDs”


NCD prevention – broad impact• NDC’s, their treatment and the related inequities in

health hamper social and economic development• NCD prevention through health promotion and policies in

different sectors (”Health in all policies” does not onlyimprove public health but contributes to sustainablesocial and economic development

• NCD prevention helps (in addition to public health) to– Control health care costs– Care of elderly– Increase labour productivity– Increase general wellbeing


• NCD prevention and control is possible and pays off• Population based NCD prevention by appropriate

policies and health promotion activities is the mosteffective way to improve public health

• Comprehensive action, broad collaboration with dedicated leadership and strong government policy support in different areas are needed

• Prevention through influencing NCD related lifestylesis also the way to support sustainable social and economic development


Conclusion

46

Vision• Prevention of avoidable NCD

mortality through sustainable social change process

• ”More years in life – more life in years”

• ”Health for all”



For succesful prevention

Strong leadership combined withGood partnership

* * *Do the right thingsDo enough of those

3.12.2013

Thank you


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